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Slide 2 The physician-patient relationship is the cornerstone of medical practice and therefore of medical ethics. As noted above, the Declaration of Geneva requires of the physician that The health of my patient will be my first consideration, and the International Code of Medical Ethics states, A physician shall owe his/her patients complete loyalty and all the scientific resources available to him/her. Slide 3 This section will deal with six topics that pose particularly vexing problems to physicians in their daily practice: Respect and equal treatment; Communication and consent; Decision making for incompetent patients; Confidentiality; Beginning-of-life issues; End-of-life issues. Slide 4 Respect and Equal Treatment The Universal Declaration of Human Rights (1948), which states in article 1, All human beings are born free and equal in dignity and rights. A physicians conscience, rather than the law or disciplinary authorities, may be the only means of preventing abuses of human rights in this regard. Even if physicians do not offend against respect and human equality in their choice of patients, they can still do so in their attitudes towards and treatment of patients. Slide 5 Compassion is based on respect for the patients dignity and values but goes further in acknowledging and responding to the patients vulnerability in the face of illness and/or disability. If patients sense the physicians compassion, they will be more likely to trust the physician to act in their best interests, and.this trust can contribute to the healing process Slide 6 This could be an example on discrimination The WMAs Statement on HIV/AIDS and the Medical :Profession puts it this way Unfair discrimination against HIV/AIDS patients by physicians must be eliminated completely from the practice of medicine. All persons infected or affected by HIV/AIDS are entitled to adequate prevention, support, treatment and care with compassion and respect for human dignity. Slide 7 Communication and Consent The patient has the right to self-determination, to make free decisions regarding himself/herself. The physician will inform the patient of the consequences of his/her decisions. A mentally competent adult patient has the right to give or withhold consent to any diagnostic procedure or therapy. The patient has the right to the information necessary to make his/her decisions. Slide 8 A necessary condition for informed consent is good communication between physician and patient. When medical paternalism was normal, communication was relatively simple; it consisted of the physicians orders to the patient to comply with such and such a treatment. Nowadays communication requires much more of physicians. They must provide patients with all the information they need to make their decisions. Slide 9 This involves explaining complex medical diagnoses, prognoses and treatment regimes in simple language, ensuring that patients understand the treatment options, and so on. Two major obstacles to good physician-patient communication are: differences of language and culture. If the physician and the patient do not speak the same language, an interpreter will be required. Culture, which includes but is much broader than language, raises additional communication issues. Slide 10 If the physician has successfully communicated to the patient all the information the patient needs and wants to know, the patient will then be in a position to make an informed decision about how to proceed. The principle of informed consent incorporates the patients right to choose from among the options presented by the physician. Competent patients have the right to refuse treatment even when the refusal will result in disability or death. Slide 11 Decision-making for incompetent patient Many patients are not competent to make decisions for themselves. Examples include young children, individuals affected by certain psychiatric or neurological conditions, and those who are temporarily unconscious or comatose. If the patient is unconscious or otherwise unable to express his/her will, informed consent must be obtained, whenever possible, from a legally entitled representative. Physicians have the same duty to provide all the information the substitute decision-makers need to make their decisions. Slide 12 The principal criteria to be used for treatment decisions for an incompetent patient are his or her preferences, if these are known. The preferences may be found in an advance directive or may have been communicated to the designated substitute decision-maker, the physician or other members of the healthcare team. Slide 13 When an incompetent patients preferences are not known, treatment decisions should be based on the patients best interests, taking into account: (a) The patients diagnosis and prognosis; (b) The patients known values (c) Information received from those who are significant in the patients life and who could help in determining his/her interests. (d) Aspects of the patients culture and religion that would influence a treatment decision. Slide 14 Patients suffering from psychiatric or neurological disorders who are judged to pose a danger to themselves or to others raise particularly difficult ethical issues It is important to honor their human rights, especially the right to freedom, to the greatest extent possible issues. Nevertheless, they may have to be confined and/or treated against their will in order to prevent harm to themselves or others. Slide 15 Confidentiality The physicians duty to keep patient information confidential has been a cornerstone of medical ethics since the time of Hippocrates. It is also important because human beings deserve respect. One important way of showing them respect is by preserving their privacy. The WMA Declaration on the Rights of the Patient summarizes the patients right to confidentiality as follows: Slide 16 All identifiable information about a patient's health status, medical condition, diagnosis, prognosis and treatment and all other information of a personal kind, must be kept confidential, even after death. Exceptionally, the descendents may have a right of access to information that would inform them of their health risks. Confidential information can only be disclosed if the patient gives explicit consent or if expressly provided for in the law. Information can be disclosed to other healthcare providers only on a strictly "need to know" basis unless the patient has given explicit consent. Slide 17 All identifiable patient data must be protected. The protection of the data must be appropriate to the manner of its storage. Human substances from which identifiable data can be derived must be likewise protected. Slide 18 If physicians are persuaded to comply with legal requirements to disclose their patients medical information, it is desirable that they discuss with the patients the necessity of any disclosure before it occurs and enlist their co-operation. Physicians may have an ethical duty to impart confidential information to others who could be at risk of harm from the patient. Two situations in which this can occur are: When a patient tells a psychiatrist that he intends to harm another person When a physician is convinced that an HIV-positive patient is going to continue to have unprotected sexual intercourse with his spouse or other partners. Slide 19 When a physician has determined that the duty to warn justifies an unauthorized disclosure, two further decisions must be made: Whom should the physician tell? How much should be told? Generally speaking, the disclosure should contain only that information necessary to prevent the anticipate harm and should be directed only to those who need the information in order to prevent the harm. Slide 20 Beginning-of-life Issues Many of the most prominent issues in medical ethics relate to the beginning of human life. It is worth listing these issues so that they can be recognized as ethical in nature and dealt with as such. Contraception Assisted reproduction Prenatal genetic screening Abortion Severely compromised neonates Research issues Slide 21 Contraception Although there is increasing international recognition of a womans right to control her fertility, including the prevention of unwanted pregnancies, physicians still have to deal with difficult issues such as requests for contraceptives from minors and explaining the risks of different methods of contraception. Slide 22 Assisted reproduction There are various techniques of assisted reproduction, such as artificial insemination and in-vitro fertilization and embryo transfer, widely available in major medical centers. None of these techniques is unproblematic, either in individual cases or for public policies. Slide 23 Prenatal genetic screening Genetic tests are now available for determining whether an embryo or fetus is affected by certain genetic abnormalities and whether it is male or female. Slide 24 Depending on the findings, a decision can be made whether or not to proceed with pregnancy. Physicians need to determine when to offer such tests and how to explain the results to patients. Slide 25 Abortion This has long been one of the most divisive issues in medical ethics, both for physicians and for public authorities. The WMA Statement on Therapeutic Abortion acknowledges this diversity of opinion and belief and concludes that This is a matter of individual conviction and conscience that must be respected. Slide 26 In Islam as a moderate religion, birth control is allowed but abortion is forbidden since no Aya or Hadith prohibits birth control. Slide 27 Severely compromised neonates Because of extreme prematurity or congenital abnormalities, some neonates have a very poor prognosis for survival. Difficult decisions often have to be made whether to attempt to prolong their lives or allow them to die. Slide 28 Research issues These include the production of new embryos or the use of spare embryos (those not wanted for reproductive purposes) to obtain stem cells for potential therapeutic applications, testing of new techniques for assisted reproduction, and experimentation on fetuses. Slide 29 End-of-life Issues End-of-life issues range from attempts to prolong the lives of dying patients through highly experimental technologies, such as the implantation of animal organs, to efforts to terminate life prematurely through euthanasia and medically assisted suicide. Two issues deserve particular attention: Euthanasia Assistance in suicide Slide 30 Euthanasia: Means knowingly and intentionally performing an act that is clearly intended to end another persons life and that includes the following elements: the subject is a competent informed person with an incurable illness who has voluntarily asked for his or her life to be ended; the agent knows about the persons condition and desire to die, and commits the act with the primary intention of ending the life of that person; and the act is undertaken with compassion and without personal gain. Slide 31 Euthanasia, or assistant in suicide that is the act of deliberately ending the life of a patient, even at the patients own request or at the request of close relatives, is unethical. This does not prevent the physician from respecting the desire of a patient to allow the natural process of death to follow its course in the terminal phase of sickness. Slide 32 In recent years there have been great advances in palliative care treatments for relieving pain and suffering and improving quality of life Slide 33 The WMAs International Code of Medical Ethics implies that the only reason for ending a physician- patient relationship is: if the patient requires another physician with different skills: A physician shall owe his/her patient complete loyalty and all the scientific resources available to him/ her. Whenever an examination or treatment is beyond the physicians capacity, he/she should consult with or refer to another physician who has the necessary ability. Slide 34 However, there are many other reasons for a physician wanting to terminate a relationship with a patient, for example: the physicians moving or stopping practice, the patients refusal or inability to pay for the physicians services, dislike of the patient and the physician for each other the patients refusal to comply with the physicians recommendations, etc. Slide 35 Case Study #1 Dr. P, an experienced and skilled surgeon, is about to finish night duty at a medium sized community hospital. A young woman is brought to the hospital by her mother, who leaves immediately after telling the intake nurse that she has to look after her other children. The patient is bleeding vaginally and is in a great deal of pain. Dr. P examines her and decides that she has had either a miscarriage or a self-induced abortion. He does a quick dilatation and curettage and tells the nurse to ask the patient whether she can afford to stay in the hospital until it is safe for her to be discharged. Dr. Q comes in to replace Dr. P, who goes home without having spoken to the patient. Slide 36 Cornerstone Pose Vexing problems Incompetent Dignity Compassion Conscience Paternalism Interpreter Slide 37 Prognosis Vulnerability Psychiatric Neurological Comatose Diagnosis Disclosed Major obstacles Slide 38 Psychiatric condition Neurological conditions Entitled representative Incompetent patient Pose Prevent harm Descendents Human substances Slide 39 Contraception Assisted reproduction Prenatal genetic screening Abortion Severely compromised Neonates Euthanasia Suicide Slide 40 Incurable illness Voluntarily Terminate Palliative Relieving pain